## Algorithm For Using Currently Available Drugs

Guidance on the use of medications to treat obesity can be found in a variety of sources (7-9). One algorithm recently proposed is by the American College of Physicians (9). It provides an organized approach and a framework to comment on drugs for the treatment of obesity. As a document prepared by physicians, it emphasizes the medical model in which drugs are used to treat symptoms. However, the algorithm shown in Fig. 1, from a National Heart, Lung, and Blood Institute (NHLBI) report, is a more versatile algorithm.

The first step is to measure height and weight to establish the body mass index (BMI) for the patient. If the BMI, the weight in kilograms divided by the square of the height in meters (kg/m2) (weight in pounds divided by square of the height in inches times 703), is higher than 30, the patient is by definition in the obese category and medications can be considered. Not mentioned in this guideline is the essential next step of measuring waist circumference (for individuals with a BMI < 35—if the BMI is above 35, the waist circumference will almost certainly be increased). The currently recommended upper limit for waist circumference is 102 cm (40 in.) for a man and 88 cm (35 in.) for a woman. Values above these numbers have the same meaning as a BMI ;30 kg/m 2

Another important initial step is to assess the associated (comorbid) conditions by measuring blood pressure, glucose, and lipids, and, when indicated, performing other tests. With this laboratory panel and the waist circumference, the presence of metabolic syndrome can be diagnosed. This is best done using the criteria from the National Cholesterol Education Panel Adult Treatment III Guidelines that are shown in Table 1, although other classification schemes are available.

Once it is established that the patient is an appropriate candidate to lose weight and that he or she is motivated to do so, the next step is to set a weight loss goal. Most patients have an unrealistic view of how much weight they can lose. For them a weight loss of less than 15% would often be viewed as a failure. In contrast, the goal with monotherapy with the drugs described here that are currently available is not more than 10% for most patients. It is thus important for physician and patient alike to set a weight-loss goal for initial therapy that is not more than 10% and to set a lower limit for weight loss of not less than 5%, which will suggest that an alternative strategy is needed.

The next step is to be certain that the patient is "ready" to lose weight. Using ideas from psychology, we need to have the patient ready to work on weight loss, as opposed to not yet thinking about the problem. Once the weight goal is established and the patient is prepared to take charge of the weight-loss program, the next steps are to help develop lifestyle changes that will benefit the program. The most important of these are monitoring what is eaten, where it is eaten, and under what circumstances. A second element is to provide dietary advice. Replacing voluntary choices with "portion-controlled"

OJ OJ

C Patient Encounter )

C Patient Encounter )

Reinforcement/ educate on weight management

Advise maintain weight/ address other risk factors

Reinforcement/ educate on weight management

Advise maintain weight/ address other risk factors

 Examination -16 ♦♦ Maintenance counseling: Periodic Weight Check Treatment • Diet i i * Behavior therapy * Exercise

Assess reasons for failure to lose weipht

Fig. 1. Algorithm for use of drags to treat obesity.

Assess reasons for failure to lose weipht

Fig. 1. Algorithm for use of drags to treat obesity.

Table 1

Clinical Features of Metabolic Syndrome^

Risk factor

Defining level

Abdominal obesity (waist circumference) Men Women

High-density lipoprotein cholesterol Men Women Triglycerides Fasting glucose Blood pressure Systolic Diastolic

<40 mg/dL <50 mg/dL >150 mg/dL >110 mg/dL

Metabolic syndrome is present if 3 of the 5 risk factors are abnormal. Modified from ref. 134.

foods at one or more meals can be useful. There are frozen foods, ready-to-make food items, and meal replacements that can be used for this purpose. The patient also needs more exercise; one strategy is to have the patient get a pedometer, or "step-counter," and to records the number of steps taken, with the goal of gradually increasing it to 10,000 steps per day. When the patient returns, you establish whether the patient has met the goals. If so, the patient may continue as is, but if after 3 mo the patient fails to meet the goals, then medications may be considered.

The American College of Physicians (ACP) guidelines appropriately suggest discussing the pros and cons of medication with the patient and having a consent form signed for the use of medications to treat obesity. The algorithm then goes on to recommend six medications: orlistat, sibutramine, phentermine, diethylpropion, fluoxetine, and bupropion. Two other drugs, topiramate and zonisamide, are also mentioned in the ACP paper, but not included as "recommended" drugs in the algorithm. In our view, two of the drugs that are included in the algorithm, fluoxetine and bupropion, should be used only in special conditions. Fluoxetine is appropriate for the overweight patient who is depressed. Bupropion can be helpful in reducing or preventing weight gain when people try to stop smoking and when they are depressed. We will review each of these drugs below.

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